A new divide in American death

An urban-rural mortality gap emerges among whites as risky behaviors work to defy modern trends

White women have been dying prematurely at higher rates since the turn of this century, passing away in their 30s, 40s and 50s in a slow-motion crisis driven by decaying health in small-town America, according to an analysis of national health and mortality statistics by The Washington Post.

Among African Americans, Hispanics and even the oldest white Americans, death rates have continued to fall. But for white women in what should be the prime of their lives, death rates have spiked upward. In one of the hardest-hit groups — rural white women in their late 40s — the death rate has risen by 30 percent.

UNNATURAL CAUSES: SICK AND DYING IN SMALL-TOWN AMERICA

Since the turn of this century, death rates have risen for whites in midlife, particularly women. In this series, The Washington Post is exploring this trend and the forces driving it. Read the entire series.

The Post’s analysis, which builds on academic research published last year, shows a clear divide in the health of urban and rural Americans, with the gap widening most dramatically among whites. The statistics reveal two Americas diverging, neither as healthy as it should be but one much sicker than the other.

In modern times, rising death rates are extremely rare and typically involve countries in upheaval, such as Russia immediately after the collapse of the Soviet Union. In affluent countries, people generally enjoy increasingly long lives, thanks to better cancer treatments; drugs that lower cholesterol and the risk of heart attacks; fewer fatal car accidents; and less violent crime.

But progress for middle-aged white Americans is lagging in many places — and has stopped entirely in smaller cities and towns and the vast open reaches of the country. The things that reduce the risk of death are now being overwhelmed by things that elevate it, including opioid abuse, heavy drinking, smoking and other self-destructive behaviors.

White men are also dying in midlife at unexpectedly high rates. But the most extreme changes in mortality have occurred among white women, who are far more likely than their grandmothers to be smokers, suffer from obesity or drink themselves to death.

White women still outlive white men and African Americans of both sexes. But for the generations of white women who have come of age since the 1960s, that health advantage appears to be evaporating.

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Public health experts say the rising white death rate reflects a broader health crisis, one that has made the United States the least healthy affluent nation in the world over the past 20 years. The reason these early deaths are so conspicuous among white women, these experts say, is that in the past the members of this comparatively privileged group have been unlikely to die prematurely.

Laudy Aron, a researcher with the Urban Institute, said rising white death rates show that the United States’ slide in overall health is not being driven simply by poor health in historically impoverished communities.

“You can’t explain it away as, ‘It’s those people over there who are pulling us down,’ ” Aron said. “We’re all going down.”

For this article, The Post examined death records from the Centers for Disease Control and Prevention, breaking the information down geographically, county by county, by level of urbanization and by cause of death.

Big cities and their suburbs — metropolitan areas of more than 1 million people — looked strikingly different from the rest of the country. The Post divided these populations into urban and rural categories, with the rural population encompassing smaller cities as well as small towns and the most remote places.

Beverly Layman, 58, died in March from complications due to liver failure. Layman's liver failed as the result of long-term use of alcohol, painkillers, anti-anxiety medications and illicit drugs. She died two weeks before her 59th birthday. In her will, Layman left $100,000 to Teen Challenge, a faith-based organization that helps teen-agers struggling with drug and alcohol addiction. (Bonnie Jo Mount/The Washington Post)

The statistics show decaying health for all white women since 2000. The trend was most dramatic for women in the more rural areas. There, for every 100,000 women in their late 40s, 228 died at the turn of this century. Today, 296 are dying. And in rural areas, the uptick in mortality was noticeable even earlier, as far back as 1990. Since then, death rates for rural white women in midlife have risen by nearly 50 percent.

In the hardest-hit places — 21 counties arrayed across the South and Midwest — the death rate has doubled, or worse, since the turn of the century for white women in midlife.

In Victoria County, Tex., a rural area near the Gulf Coast, deaths among women 45 to 54 have climbed by 169 percent in that time period, the sharpest increase in that age group of any U.S. county. The death rate climbed from 216 per 100,000 people to 583.

Lisa Campbell, medical director for the Victoria County health department, said a third of adults in the county are obese, roughly in line with the national average. Also, 1 in 5 smokes — well above the national average — and people can still light up in restaurants and other public places.

Campbell said she has been struck by how many white women she knows who have some kind of cancer.

“It’s kind of weird, actually,” she said.

Change in mortality

for white women between 35-54

Increase 0 - 12.5%

12.5 - 25

25 - 40

>40

INCREASING DEATH RATES

From 1990 through 2014, the mortality rate for white women rose in most parts of the country, particularly around small cities and in rural areas. Rates often went up by more than 40 percent and, in some places, doubled.

Decrease 0 - 6%

>6%

DECLINING DEATH RATES

Mortality rates were most likely to decline in the Northeast corridor and in large cities that anchor metropolitan areas of more than a million people, including Chicago, Los Angeles, Miami, St. Louis and Houston.

Source: Washington Post analysis of Centers for Disease Control and Prevention mortality data

Changes in death rates for

white women ages 35 to 54 since 1990

Increase 0 - 12.5%

12.5 - 25

25 - 40

>40

INCREASING DEATH RATES

From 1990 through 2014, the mortality rate for white women rose in most parts of the country, particularly around small cities and in rural areas. Rates often went up by more than 40 percent and, in some places, doubled.

Decrease 0 - 6%

>6%

DECLINING DEATH RATES

Mortality rates were most likely to decline in the Northeast corridor and in large cities that anchor metropolitan areas of more than a million people, including Chicago, Los Angeles, Miami, St. Louis and Houston.

Source: Washington Post analysis of Centers for Disease Control and Prevention mortality data

Changes in death rates for white women ages 35 to 54 since 1990

Increase 0 - 12.5%

12.5 - 25

25 - 40

>40

Decrease 0 - 6%

>6%

INCREASING DEATH RATES

DECLINING DEATH RATES

From 1990 through 2014, the mortality rate for white women rose in most parts of the country, particularly around small cities and in rural areas. Rates often went up by more than 40 percent and, in some places, doubled.

Mortality rates were most likely to decline in the Northeast corridor and in large cities that anchor metropolitan areas of more than a million people, including Chicago, Los Angeles, Miami, St. Louis and Houston.

Source: Washington Post analysis of Centers for Disease Control and Prevention mortality data

White women remain an advantaged demographic, just less so, year by year. Four decades ago, the average white American woman lived eight years longer than the average white American man. Today, that health advantage has narrowed to just five years.

What we’re seeing is “the shrinking protective effect of gender in life expectancy,” said former U.S. assistant surgeon general Susan Blumenthal, a women’s-health expert.

Multiple factors are converging to produce this corrosion of American health. Foremost is an epidemic of opioid and heroin overdoses that has been particularly devastating in working-class and rural communities.

Another killer is related to heavy drinking. Deaths of rural white women in their early 50s from cirrhosis of the liver have doubled since the end of the 20th century, The Post found.

Suicides are also on the rise. The suicide rate is climbing for white women of all ages and has more than doubled for rural white women ages 50 to 54.

Other trends may be contributing to the die-off, including obesity. Americans are the heaviest people in the world outside of a few Pacific Island nations; more than a third of adults in the United States are considered obese. The average American woman today weighs as much as an American man did in the early 1960s.

Obesity causes its own kind of liver disease and can be lethal in combination with other conditions, such as diabetes, heart attacks and strokes.

Every death is unique, with its own narrative, often one that is complicated and, in the deepest sense, personal. There are many paths to that final destination. Medical experts refer to “morbidity,” a catchall term for the rate of serious illnesses.

“I try to emphasize: It’s not just mortality — it’s also morbidity,” said Princeton University economist Anne Case, lead author of the much-publicized study that late last year drew national attention to rising mortality among middle-aged whites, particularly among those with a high school education or less. “There are millions of people underneath these graphs who are in pain.”

Anne Case and her husband Angus Deaton, both Princeton University economists, published a study late last year that drew national attention to rising mortality among middle-aged whites. (Yana Paskova for The Washington Post)

Researchers circled the dying-whites phenomenon for several years before clearly recognizing what they were seeing. In 2014, the increase in the death rate of relatively young white women was right there in the CDC’s massive annual report on American health, but it drew no comment in the introductory highlights. Readers had to scrutinize Table 23 on Page 109 to spot the trend.

Other reports were more explicit. A 2013 study at the University of Wisconsin looked at the geography of death and discovered that mortality for women of all races had risen in 43 percent of U.S. counties between 1992 and 2006. Men’s mortality had risen in only 3 percent of counties.

Also in 2013, a sweeping study, “Shorter Lives, Poorer Health,” from the National Research Council and the National Academies’ Institute of Medicine showed a broad “health disadvantage” among Americans, compared with people in other affluent countries.

Aron, the Urban Institute researcher who co-authored the study, wrote in January 2014 that “increases in mortality are especially pronounced among white women of reproductive age, not a group we generally think of as being disadvantaged.” Last year, she and two co-authors published a separate article highlighting the perplexing number of white women who are dying prematurely.

Then, in November, Case and her husband, Angus Deaton, another Princeton economics professor, published their paper in the Proceedings of the National Academy of Sciences. Deaton had recently won the Nobel Prize in economics, an honor that added media gloss to the dying-whites study. Suddenly, it was a national story.

Other researchers weighed in, debating aspects of the Case-Deaton statistical analysis. For example, their study played down differences in gender; Case and Deaton contend that the noticeably higher death rates for women were largely driven by smoking patterns.

In Alabama, the death rate for white women ages 35 to 54 has increased, while the rate for black women in that age range has decreased.

500 deaths per 100,000 people

Black women

400

300

White women

200

100

0

1999

2014

This has occurred even though poverty rates in the state are virtually unchanged.

40% poverty rate

Black

30

20

White

10

0

2005

2014

Source: Washington Post analysis of Centers for Disease Control and Prevention mortality data

Others have questioned the sudden focus on whites, pointing out that African Americans continue to have shorter life spans and face severe health challenges exacerbated by racial segregation and discrimination. Why, they ask, give so much attention to a group that remains statistically advantaged?

“The truth is that white death rates are still much, much lower than they are for African Americans,” said Bridget Catlin, senior scientist at the University of Wisconsin. “My concern is that people will think, ‘Oh, it’s whites that need to be helped.’ ”

Catlin is co-director of a program, sponsored by the Robert Wood Johnson Foundation, that has found a growing divide between urban and rural health consistent with The Post’s findings — and implicitly consistent with Case and Deaton’s, since whites are a large majority in most rural areas.

Case said that the whites who are dying are not America’s elites.

“They may be privileged by the color of their skin,” she said, “but that is the only way in their lives they’ve ever been privileged.”

In at least 30 counties in the South, black women in midlife now have a lower mortality rate than middle-aged white women, The Post found. That’s up from a single such county in 1999.

Among them is Newton County, Ga., southeast of Atlanta, where the death rate for black women ages 35 to 54 dropped from 472 per 100,000 to 234. The rate for white women went the other way, from 255 to 472.

Theories abound about what has sparked the die-off. Researchers have noted that a powerful opioid, oxycodone, won regulatory approval and its use became widespread around the time white death rates began to rise.

But overdoses account for only a portion of the extra deaths; something else is going on.

“The stressors have increased,” said Janine Clayton, director of the Office of Research on Women’s Health at the National Institutes of Health. “If it’s affecting women who previously had better health, how might it even more deleteriously affect women who previously had borderline health?”

Researchers point out that this generation of white women has experienced a revolutionary change in gender roles over the past half-century, surging into the workforce while typically retaining traditional duties as domestic caregivers — a dual role to which many women of color have long been accustomed. White women often find themselves harried in ways their grandmothers could never have imagined.

“I think we are undergoing a change that’s comparable to the Industrial Revolution,” Aron said. “Those of us who are lucky enough to have jobs are sort of clinging to them for dear life.”

Amid these social changes, American women collectively became more likely to engage in risky behaviors, health experts say. There is a declining difference, for example, between men and women in the consumption of alcohol, said George Koob, director of the National Institute on Alcohol Abuse and Alcoholism.

Men are still more likely to abuse alcohol, Koob said, but women tend to experience a “telescoping” of the negative outcomes and more quickly develop alcohol-related diseases. Koob noted that alcohol abuse can be particularly deadly in combination with obesity, which is rampant in rural America.

“I think that’s what you’re picking up, is insults to the liver,” Koob said of The Post’s findings.

Women in middle age also are more likely to smoke or to have smoked at some point in their lives, and smoking-related diseases are a huge factor in women’s mortality. When men began quitting cigarettes in large numbers in the 1960s and 1970s, the smoking gap between men and women nearly vanished.

Lung cancer now kills far more women than breast cancer.

Leading causes

Drug overdose, suicide and cirrhosis of the liver, usually linked to heavy drinking, are the biggest factors in the increasing overall death rate for middle-aged white women. Metropolitan areas of at least 1 million people had smaller increases than the more rural group that included smaller cities and towns.

Age 30-34

35-39

40-44

OVERDOSE

Rural

Urban

’99

’14

’99

’14

Death rate

(deaths per

100,000

white

women)

30

Age 45-49

25

20

45-49

15

10

50-54

50-54

5

0

Suicide

Rural

Urban

’99

’14

’99

’14

Death rate

(deaths per

100,000

white

women)

20

45-49

50-54

15

50-54

10

45-49

5

0

CIRRHOSIS

Rural

Urban

’99

’14

’99

’14

Death rate

(deaths per

100,000

white

women)

20

50-54

15

50-54

45-49

10

45-49

5

0

Source: Washington Post analysis of Centers for Disease Control and Prevention mortality data

Leading causes

Drug overdose, suicide and cirrhosis of the liver, usually linked to heavy drinking, are the biggest factors in the increasing overall death rate for middle-aged white women. Metropolitan areas of at least 1 million people had smaller increases than the more rural group that included smaller cities and towns.

Age 30-34

35-39

40-44

Death rate

(deaths per100,000

white women)

10

15

20

25

30

0

5

’99

50-54

Age 45-49

Rural

’14

’99

Overdose

Urban

50-54

45-49

’14

’99

Rural

50-54

45-49

’14

’99

Suicide

Urban

50-54

45-49

’14

’99

Rural

50-54

45-49

’14

Cirrhosis

’99

Urban

45-49

50-54

’14

Source: Washington Post analysis of Centers for Disease Control and Prevention mortality data

Leading causes

Drug overdose, suicide and cirrhosis of the liver, usually linked to heavy drinking, are the biggest factors in the increasing overall death rate for middle-aged white women. Metropolitan areas of at least 1 million people had smaller increases than the more rural group that included smaller cities and towns.

Age 30-34

35-39

40-44

Overdose

Suicide

Cirrhosis

Rural

Urban

Rural

Urban

Rural

Urban

’14

’14

’14

’14

’14

’14

’99

’99

’99

’99

’99

’99

30

Age 45-49

25

20

50-54

45-49

45-49

50-54

15

50-54

50-54

10

45-49

45-49

45-49

50-54

50-54

5

Death rate

(deaths per

100,000

white women)

0

Source: Washington Post analysis of Centers for Disease Control and Prevention mortality data

Different racial and ethnic groups have distinct health profiles and particular challenges. Black women with breast cancer are more likely to die from it, for example, even though white women have higher rates of the disease. Blacks also have much higher rates than whites of heart disease, hypertension, diabetes and asthma and are less likely to have health insurance.

Whites stand out for their high rate of opioid use. Americans represent 5 percent of the world’s population but consume at least 80 percent of its prescription opioids. And whites, for complex sociological and economic reasons, are far more likely than blacks or Hispanics to be prescribed opioids.

People hooked on opioids often turn to street heroin, which gives the same effect and is cheaper. A medical study last year reported that 90 percent of the people who tried heroin for the first time in the past decade were white. Meanwhile, overdoses from painkillers, heroin and other opiates have been rising faster among women.

The CDC recently responded to the opioid epidemic with new guidelines for how and when doctors should prescribe these powerful drugs. The CDC did not issue gender-specific recommendations for men and women except for ones related to pregnancy; Blumenthal, the women’s-health specialist, said sex differences are often overlooked in research reporting, as well as in clinical treatment.

In Walker County, Ala., less than an hour northwest of Birmingham, the population of 65,000 is 91 percent white, and opiate addiction is rampant. The coal mines have been shutting down for decades. Nearly 1 in 5 working-age people are listed as disabled. Since 1999, the death rate for white women 35 to 44 has jumped 170 percent, The Post found.

The county’s sheriff says that 4 out of 5 arrests are for drug-related crimes.

“When we see somebody dead under 50, we automatically think drugs,” said Walker County Circuit Clerk Susan Odom, whose sister died of a drug overdose. “Died at home? Drugs.”

Members of the St. Louis Regional Heroin Initiative prepare to execute a heroin raid on a residential property in Saint Peters, Mo. (Ricky Carioti/The Washington Post)

Some regions are hit especially hard, such as the belt of poverty and pain that runs across the northern tier of the South, incorporating much of West Virginia, Kentucky, Tennessee and Arkansas. But significant increases in white mortality also showed up in the small-town and rural Midwest — such as Johnson County, Iowa, home of the University of Iowa — and in parts of the American West, such as Nye County, Nev., and Siskiyou County, Calif.

No region is completely free of the trend. The big exceptions are the major cities, such as New York, Los Angeles, Chicago, Washington and Houston. There, the death rate for whites has continued to fall, but less dramatically than for blacks and Hispanics.

Men feel these forces, too. The Post found a sharp rise in mortality among men 25 to 35 — a prime age for overdoses. An older generation has also stumbled: The Post’s analysis showed that, since 2008, when the nation descended into the Great Recession, the death rate for white men 55 to 64 has marched upward.

In general, men are significantly more likely to die prematurely than women. And because the male death rate is relatively high to begin with, a small spike, or even a failure to drop as expected, can mean of lot of funerals.

Compared with a scenario in which mortality rates for whites continued to fall steadily after 1998, roughly 650,000 people have died prematurely since 1999 — around 450,000 men and nearly 200,000 women.

That number nearly equals the death toll of the American Civil War.

Change in mortality rate,

urban vs. rural

White women and men in small cities and rural areas are dying at much higher rates than in 1990, while whites in the largest cities and their suburbs have steady or declining death rates.

Rural

Age 25

55

Urban

Age 25

55

50%

Death

rate

increases

FEMALE

25

0

-20

Death

rate

decreases

-40

2014

1990

50%

Death

rate

increases

MALE

25

0

-20

Death

rate

decreases

-40

2014

1990

Source: Washington Post analysis of Centers for Disease Control and Prevention mortality data

Change in mortality rate, urban vs. rural

White women and men in small cities and rural areas are dying at much higher rates than in 1990, while whites in the largest cities and their suburbs have steady or declining death rates.

Rural

Urban

Age 25

55

Age 25

55

50%

40

Death

rate

increases

MALE

FEMALE

30

20

10

0

-10

-20

Death

rate

decreases

-30

-40

1990

2014

1990

2014

Source: Washington Post analysis of Centers for Disease Control and Prevention mortality data

Change in mortality rate, urban vs. rural

White women and men in small cities and rural areas are dying at much higher rates than in 1990, while whites in the largest cities and their suburbs have steady or declining death rates.

Rural

Urban

Age 25

55

Age 25

55

50%

40

MALE

FEMALE

30

Death

rate

increases

20

10

0

-10

Death

rate

decreases

-20

-30

-40%

1990

2014

1990

2014

Source: Washington Post analysis of Centers for Disease Control and Prevention mortality data

The Norman Rockwell vision of America was always heavily idealized, but the country has changed in fundamental ways over the past half-century. We are now an urban society. Left behind are small towns and small cities where the kids leave after high school graduation, the churches struggle to stay open and the biggest business in town is often the local hospital.

In Bakersfield, Calif., a city in heavily agricultural Kern County, Samantha Burton, 42, was addicted to painkillers for a decade but has been clean for more than two years. She said her problem started with a prescription for Percocet after she got a bad case of food poisoning.

“This can be a very stifling place. It’s culturally barren,” she said of Bakersfield. “There is no place where children can go and see what it’s like to be somewhere else, to be someone else. At first, the drugs are an escape from your problems, from this place, and then you’re trapped.”

One theory about what is causing rising mortality among whites is the “dashed expectations” hypothesis. According to Johns Hopkins University sociologist Andrew Cherlin, whites today are more pessimistic than their forebears about their opportunities to advance in life. They are also more pessimistic than their black and Hispanic contemporaries.

“The idea that today’s generations will do better than their parents’ generation is part of the American Dream. It has always been true until now,” Cherlin said. “It may still be true for college-educated Americans, but not for the high-school-educated people we used to call the working class.”

Cherlin said whites benefited from discriminatory hiring when the working class was built over much of the past century. Union jobs tended to go to whites, he said, and labor contracts protected them until the unions lost power and jobs went overseas.

“Whites had a privileged place in the blue-collar economy,” he said. And as the middle of the labor market disappeared, so did that historic white privilege.

Predominantly white, working-class areas with high death rates have proved to be fertile ground for Trump. Political observers speculate that the voter anger driving his campaign emerges from the many distresses felt in these economically challenged — and increasingly morbid — places.

The wave of lethal agents rolling across the country is broad in its effects, but it appears to be cresting in places that are particularly vulnerable — such as a town where the trains no longer stop, or a small city that saw its biggest manufacturer move overseas, or in a household broken by divorce or substance abuse or tragedy.

Or in the mind and body of someone who is doing poorly, and just barely hanging on.

Since the turn of this century, death rates have risen for whites in midlife, particularly women. In this series, The Washington Post is exploring this trend and the forces driving it.�Read the entire series.